Provider Demographics
NPI:1164159059
Name:KELLEY STAHR, TAMMIE L (RN)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:L
Last Name:KELLEY STAHR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 LACKAWANNA AVE LOT 12
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-3201
Mailing Address - Country:US
Mailing Address - Phone:570-204-2809
Mailing Address - Fax:
Practice Address - Street 1:1001 S RAISINVILLE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9754
Practice Address - Country:US
Practice Address - Phone:734-243-7340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704392600163WC1500X
PARN616419163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health